Nocturia

Nocturia

1. NOCTURIA
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. MODERATORS:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. NOCTURIA-DEFINITION
Nocturiais defined as waking because of the
desire to void during intended sleep.
It can be the result of an abnormality in the
genitourinary tract or a symptom of an
underlying medical condition.
3
Dept of Urology, GRH and KMC, Chennai.

4. INTERNATIONAL CONTINENCESOCIETY
DEFINITION
Nocturiais voiding that occurs during the hours
of sleep (voiding that is preceded and followed by
sleep).
This definition does not include the degree of
bother for the patient.
4
Dept of Urology, GRH and KMC, Chennai.

5. PREVALENCE
Nocturia(>1 void per night) 28.4%, 25.2% among
men and 31.3% among women.
Prevalence of nocturiain both men and women
increases with age.
5
Dept of Urology, GRH and KMC, Chennai.

6. NOCTURIAANDSLEEPQUALITY
Nocturiaaffects sleep efficiency and sleep
latency.
6
Dept of Urology, GRH and KMC, Chennai.

7. SLEEPEFFICIENCY
Sleep efficiency is defined as actual time asleep
(minutes) divided by total time of intended sleep
(minutes).
Normal is considered greater than 85%.
<80% is associated with twice the risk of
mortality.
7
Dept of Urology, GRH and KMC, Chennai.

8. SLEEPLATENCY
Sleep latency is defined as the time it takes to go
from being completely awake to being completely
asleep.
Individuals with sleep latency more than 30 min
were found to have greater than twice the risk of
death .
8
Dept of Urology, GRH and KMC, Chennai.

9. METABOLICSYNDROME
Decreased immune function
Increased risk of CAD
Increased risk of obesity and type 2 diabetes.
Nocturiaimpairs slow wave sleep. Suppression of
slow wave sleep impairs glucose tolerance and
insulin sensitivity.
9
Dept of Urology, GRH and KMC, Chennai.

10. NOCTURIA-RISKFACTORS
Obstructive sleep apnea,
Urinary urgency,
BPH,
Snoring,
Obesity,
Antidepressant usage,
Restless leg syndrome and
Prostate cancer,
Coronary artery disease.
10
Dept of Urology, GRH and KMC, Chennai.

11. 11
Dept of Urology, GRH and KMC, Chennai.

12. 12
Dept of Urology, GRH and KMC, Chennai.

13. 13
Dept of Urology, GRH and KMC, Chennai.

14. DEFINITIONS
Night time: It is defined as the period between
going to bed with the intention of sleeping and
waking up with the intention of arising.
Total Urine Volume (TUV): Total volume of urine
produced during a 24 hour period.
First Morning Void: The first void after waking
with the intention of rising
14
Dept of Urology, GRH and KMC, Chennai.

15. DEFINITIONS
Nocturnal Urine Volume: Total volume of urine
passed during the night, including the first
morning void.
Maximum Voided Volume:Thelargest single
voided volume in a 24 hour period.
15
Dept of Urology, GRH and KMC, Chennai.

16. DEFINITIONS
Night time frequency or Actual number of nightly
voids (ANV): The number of voids recorded from
the time the individual goes to bed with the
intention of sleeping, to the time the individual
wakes with the intention of rising.
Nocturnal Polyuria: Increased production of
urine at night that is offset by lowered daytime
urine production, such that 24 hour urine volume
remains within normal limits.
16
Dept of Urology, GRH and KMC, Chennai.

17. DEFINITIONS
17
Dept of Urology, GRH and KMC, Chennai.

18. NOCTURIACLASSIFICATION
Nocturnal Polyuria
Diminished global or low nocturalbladder
capacity
Global polyuria
18
Dept of Urology, GRH and KMC, Chennai.

19. NOCTURNALPOLYURIA
Increased production of urine at night that is
offset by lowered daytime urine production, such
that 24 hour urine volume remains within
normal limits.
19
Dept of Urology, GRH and KMC, Chennai.

20. NOCTURNALPOLYURIA
Excessive nighttime fluid intake
Peripheral edema
Obstructive sleep apnea
Diabetes mellitus
Congenital heart failure
20
Dept of Urology, GRH and KMC, Chennai.

21. NOCTURNALPOLYURIA
Obstructive sleep apnea is a common cause of
nocturnal polyuria.
OSA is defined as the sudden cessation of
respiration during sleep because of airway
obstruction.
21
Dept of Urology, GRH and KMC, Chennai.

22. OSA ANDURINE
OUTPUT
Apnea
Hypoxia
Pulmonary
vasoconstriction
Increased Right
atrialpressure
Atrialnatriureteric
peptide
22
Dept of Urology, GRH and KMC, Chennai.

23. MANAGEMENT
Conservative approach.
Cessation of fluid intake 4 hours before bedtime
Use compressive lower extremity stockings
Diuretics in mid-afternoon for edema states
ADH supplementation at bedtime.
CPAP for OSA
23
Dept of Urology, GRH and KMC, Chennai.

24. DESMOPRESSIN-RECOMMENDATION
ICI: Grade A (Level 1 Evidence)
EAU: Grade A (level 1b evidence)
Women are more sensitive to desmopressinthan
man in terms of effects on nocturnal urine
production and duration of action.
Gene for V2 receptor present on X chromosome.
24
Dept of Urology, GRH and KMC, Chennai.

25. DESMOPRESSIN-PRECAUTIONS
Desmopressinis most appropriate therapy for
patients with nocturiarelated to noctural
polyuria.
Gender sensitivity differentials present.
Baseline sodium before starting therapy.
Should not be given to elderly patients with
baseline hyponatremia
Monitor sodium within 7 days and then 28 days
after initial or incremental dosing, then check
every 6 months or more often as indicated.
25
Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

27. 27
Dept of Urology, GRH and KMC, Chennai.

28. DIMINISHEDGLOBALORLOWNOCTURAL
BLADDERCAPACITY
Prostatic obstruction
Nocturnal detrusoroveractivity
Ureteralcalculi
Bladder calculi
Pharmacologic agents
Anxiety disorders
Learned voiding dysfunction
Cancer of bladder, prostate or urethra
Neurogenicbladder
28
Dept of Urology, GRH and KMC, Chennai.

29. MANAGEMENT
Treat bladder outlet obstruction (Tamsulosin
therapy and TURP).
TURP appears to be superior to Tamsulosinfor
treatment of BPH related nocturia.
29
Dept of Urology, GRH and KMC, Chennai.

30. SOLIFENACIN?
In overactive bladder?
Dose of 5 mg and 10 mg.
Decreased nocturiabut not clinically significant.
30
Dept of Urology, GRH and KMC, Chennai.

31. TOLTER
TolterodineExtended Release
Dose 4 mg, daily 4 hours before sleep
Severe OAB related nocturalmicturitions
decreased. Non OAB related nocturnal
micturitionsnot affected.
31
Dept of Urology, GRH and KMC, Chennai.

32. TROSPIUMCHLORIDE
20 mg twice daily
Significant decrease in nocturalepisodes
compared to placebo.
32
Dept of Urology, GRH and KMC, Chennai.

33. FESOTERODINE
Prodrugof tolterodine
Decreased nocturalepisodes compared to placebo.
33
Dept of Urology, GRH and KMC, Chennai.

34. MIRABEGRON
Beta 3 adrenergic agonist.
Causes decrease in nocturalmicturitionepisodes
related to overactive bladder.
34
Dept of Urology, GRH and KMC, Chennai.

35. CONCLUSION
Alpha blockers, 5 ARIs, antimuscarinicsand
antimuscarinicsplus alpha blockers have
occasionally been found to have statistically
significant reduction in nocturiaepisodes, but
clinical significance appears to be minimal.
35
Dept of Urology, GRH and KMC, Chennai.

36. MIXEDNOCTURALPOLYURIAANDDIMINISHED
GLOBALANDNOCTURNAL BLADDERCAPACITY
36% of patients have a mixed cause.
36
Dept of Urology, GRH and KMC, Chennai.

37. BEHAVIOURALMODIFICATIONS
Reduced caffeine and alcohol intake
Limited night time fluid intake
Improved sleep hygiene through moderate
exercise
Attention to room temperature, noise and
lighting.
Early evening leg elevation
Compression stockings in lower extremity edema
37
Dept of Urology, GRH and KMC, Chennai.

38. GLOBAL(24HR) POLYURIA
24 hour urine output greater than 40 ml/kg.
Increase in urinary frequency both day and night
because of global overproduction of urine in
excess of bladder capacity.
38
Dept of Urology, GRH and KMC, Chennai.

39. GLOBAL(24 HR) POLYURIA
Primary polydipsia
Diabetes insipidus
Diabetes mellitus
39
Dept of Urology, GRH and KMC, Chennai.

40. CENTRALDI-DAMAGETOHYPOTHALAMUS
ORPOSTERIORPITUITARY
Trauma,
Primary pituitary tumors
(e.g.,craniopharyngioma),
Metastatic disease (e.g.,breast, lung),
Infiltrative diseases (e.g., sarcoid),
Infarction (e.g., Sheehan syndrome postpartum),
Infection (e.g., tuberculosis, meningitis)
Idiopathic
40
Dept of Urology, GRH and KMC, Chennai.

41. NEPHROGENIC DI-NORMALADH LEVELS
BUTKIDNEYSDONOTRESPOND
Diagnosis is done by overnight water
depreviationtest and Renal concentrating
capacity test.
41
Dept of Urology, GRH and KMC, Chennai.

42. 42
Dept of Urology, GRH and KMC, Chennai.

43. POLYDIPSIA
Primary polydipsiawill have normal urine
osmolalityon water deprivation tests.
Dipsogenicpolydipsiais associated with a history
of a central neurologic abnormality such as a
history of brain trauma or radiation.
Psychogenic polydipsiais a long term behavioural
or psychiatric disorder.
43
Dept of Urology, GRH and KMC, Chennai.

44. MANAGEMENT
Central diabetes insipidus-ADH
supplementation
NephrogenicDI-No specific treatment
Primary and psychogenic polydipsia-Behavioural
therapy
Diabetes mellitus with glycosuria-Glycemic
control.
44
Dept of Urology, GRH and KMC, Chennai.

45. 45
Dept of Urology, GRH and KMC, Chennai.

46. THANKYOU
46
Dept of Urology, GRH and KMC, Chennai.